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n Case Report
Calcific Tendinitis of the Gluteus Maximus in
a Golfer
Ariel A. Williams, MD; Thomas S. Stang, BS; Jan Fritz, MD, PD, DABR; Derek F. Papp, MD
abstract
Calcific tendinitis is a relatively rare condition in which calcium is inappropriately deposited in tendons, resulting in a local inflammatory reaction
that can cause severe symptoms in certain cases. The cause of this disease
process is not completely understood, although repetitive microtrauma likely
plays a role in its development. Although the disorder most often involves
the rotator cuff, it can affect other structures throughout the body, such as the
tendons about the ankle and hip—including the rectus femoris and gluteus
maximus. Nonoperative management typically involves using an anti-inflammatory medication and activity modification and can be augmented with
formal physical therapy and modalities. Although nonoperative management
provides adequate relief for many patients, sometimes operative debridement
of the calcific deposit with or without repair of the involved tendon is required. The authors report an unusual case of calcific tendinitis of the gluteus
maximus insertion in a golfer. The patient had tried nonoperative treatment
for approximately 2 years with no real relief, and a recent exacerbation of
the pain was significantly delaying his return to sport. Although plain radiographs did not show abnormalities, magnetic resonance imaging showed a
calcific deposit in the insertion of the gluteus maximus tendon. After discussing further treatment options with the patient, the decision was made to
remove the deposit and repair the insertion. He recovered completely and
was able to return to play. The frequency, pathogenesis, and treatment of this
condition are discussed in this case report, as well as the possible link to golf
in this patient. [Orthopedics. 2016; 39(5):e997-e1000.]
C
alcific tendinitis, or calcium deposition disease, is relatively rare.
The pathogenesis involves the inappropriate sequestration of calcium into
tendons, resulting in an inflammatory reac-
tion that causes local irritation and discomfort.1 The consequences can be debilitating, with patients sometimes experiencing
severe pain and limitations in function.
Treatment varies based on the clinical se-
SEPTEMBER/OCTOBER 2016 | Volume 39 • Number 5
verity and stage of the disease, although
initial therapy is generally conservative.
The majority of cases involve the
shoulder, especially the rotator cuff. However, cases involving the peroneus longus,
rectus femoris, and other muscles have
been described.2,3 The authors report a
case of an amateur golfer presenting with
2 years of right hip pain. He was found
to have calcific tendinitis of the gluteus
maximus tendon and was treated with
surgical management because rest, medications, and therapy provided insufficient
relief. The frequency, pathogenesis, and
treatment of this condition are discussed,
as well as the possible link to golf-related
overuse.
The authors are from the Department of Orthopaedic Surgery (AAW) and the Department of
Radiology (JF), The Johns Hopkins University, Baltimore, Maryland; LMU-DeBusk College of Osteopathic Medicine (TSS), Harrogate, Tennessee; and
MedStar Health (DFP), Baltimore, Maryland.
Dr Williams, Mr Stang, and Dr Papp have no
relevant financial relationships to disclose. Dr
Fritz is an unpaid consultant for, has received a
research grant from, and is on the speaker’s bureau of Siemens Healthcare.
Correspondence should be addressed to:
Derek F. Papp, MD, 5601 Loch Raven Blvd, Ste
405, Baltimore, MD 21239 (derek.papp1@gmail.
com).
Received: November 20, 2015; Accepted:
March 8, 2016.
doi: 10.3928/01477447-20160616-08
e997
n Case Report
Figure 1: Anteroposterior radiograph of the right hip
at the time of initial presentation showing no abnormalities.
Figure 2: Coronal proton-density-weighted (A) and fat-saturated T2-weighted (B) magnetic resonance images obtained 1 week after presentation showing a focus of diminished signal intensity
(arrow, A) representing a calcific deposit in the gluteus maximus tendon with a rim of inflammatory
edema pattern (arrow, B).
Figure 3: Representative high-power (hematoxylin-eosin, original magnification ×4) (A) and low-power
(hematoxylin-eosin, original magnification ×2) (B) histologic sections taken at the time of surgery showing
vascular proliferation and calcification characteristic of calcific tendinitis.
Case Report
A 32-year-old, otherwise healthy,
male retail manager and amateur golfer
presented with right hip pain of 2 years’
duration. The onset of pain was insidious.
It had been chronic and dull until a recent
round of golf, which caused it to increase
markedly. Attempted hip motion exacerbated the pain. Conservative management
options, including nonsteroidal antiinflammatory medications and physical
therapy, provided no relief.
On physical examination, the patient
walked with a nonantalgic gait. The pa-
e998
tient had full and symmetric range of
motion of the hip. Muscle strength was
congruent and strong bilaterally. He was
tender along the gluteus maximus insertion distal to the trochanteric bursa. Radiographs showed no evidence of abnormality (Figure 1). Magnetic resonance
imaging showed a calcific lesion measuring 2×1.4 cm at the femoral insertion
of the gluteus maximus muscle approximately 4 cm distal to the right greater
trochanter (Figure 2A). There was moderate surrounding inflammation (Figure
2B) and an associated chronic partial-
thickness insertional tear of the gluteus
maximus.
Given the severity and chronicity of
his symptoms, the decision was made
to proceed surgically. A standard lateral
approach to the hip was used. After incising the tensor fascia lata, the gluteus
maximus insertion was identified. The
proximal-most aspect of the insertion had
marked tendinosis, although no gross calcinosis was observed. This region was excised and sent for pathology. The tendon
defect was then repaired and augmented
using a suture anchor and the wound was
closed. Histologic analysis of the tendon
specimen showed vascular proliferation
and calcification consistent with calcific
tendinitis (Figure 3).
At 10 months postoperatively, the patient had only an occasional ache in the
area and no tenderness. He was able to
return fully to golf and all other activities.
Discussion
Calcific tendinitis is an uncommon
entity that can cause significant pain and
discomfort. It often fails to respond to
conservative management. The pathogen-
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n Case Report
esis involves the inappropriate sequestration of calcium into tendons, resulting in
an inflammatory reaction that causes local irritation and discomfort.1 Most cases
involve the tendons of the rotator cuff,
usually the supraspinatus tendon. However, the muscles of the hip have been
estimated to be involved in 5.4% of patients older than 15 years.2 In one review
of almost 100 cases of calcific tendinitis,
Gondos4 found that the gluteus maximus
tendon was affected in 2. Other reports
of gluteus maximus calcific tendinitis
exist, but it is a relatively poorly known
entity.4-9
Because calcific tendinitis of the gluteus maximus is unusual and is associated with several nonspecific clinical and
radiologic findings, it may present a diagnostic challenge. Clinically, the signs
and symptoms may be suggestive of infection or inflammatory arthritis. In these
cases, it can be differentiated by normal
laboratory values. In addition to calcium
deposition, calcific tendinitis has also
been associated with cortical erosion on
radiographs and computed tomography
scans and soft tissue and marrow edema
on magnetic resonance images that can be
confused with infection or neoplasm.6-8
The flame-like configuration of calcium
deposition observed with calcific tendinitis along with its location at the tendon
insertion are diagnostic.6
The patient in this study was an avid
golfer. The golf swing is typically broken down into 5 phases: back swing,
forward swing, acceleration, early follow through, and late follow through. In
a golfer, electromyographic studies have
shown that the upper and lower gluteus
maximus muscles are among the most active during both the forward swing and
the acceleration phases.10 When tested
with a dynamometer, low-handicap golfers, when compared with high-handicap
golfers, have significantly higher gluteus
maximus strength.11 One other case of
gluteus maximus tendinitis in a golfer
has been described, although in that case,
the authors did not speculate as to the
pathogenesis of the patient’s condition.12
The current authors suspect that overuse
of the gluteus maximus during golf may
have played a role in both that case and
their case. Although calcific tendinitis is
not commonly described as a sports injury, overuse and repetitive microtrauma
have been posited to be involved.13 This
case highlights the importance of coaches and trainers advising golfers, both
amateur and professional, of the need to
strengthen the hip girdle muscles to help
prevent overuse syndromes.11
Calcific tendinitis is usually a selflimited disease and can be treated conservatively. In addition to nonsteroidal
anti-inflammatory medication and physical therapy, some authors describe guided
corticosteroid injections with and without needling for nonsurgical treatment
about the hip. These injections can be
either computed tomography or ultrasound guided.14-16 More recently, extracorporeal shock wave therapy has shown
promise as a nonoperative treatment modality.17 Surgery is generally reserved or
indicated for long-standing or refractory
cases. That was ultimately the case in the
current patient, who had 2 years of pain
that did not respond to therapy or medication and whose symptoms continued
to progress. The authors performed an
open excision of the affected tissue with
repair of the tendon and the patient responded well. Arthroscopic treatment of
calcific tendinitis of the gluteus medius
has been described with good results.13,16
Although some surgeons might consider
arthroscopic excision, the authors elected
to use an open approach to allow safe,
simple, and direct visualization of the
diseased tendon with an easy repair.
Conclusion
Calcific tendinitis of the gluteus maximus tendon is an unusual entity. Diagnosis can be challenging, but clinical and
radiographic studies are usually adequate.
Although it is likely multifactorial, activi-
SEPTEMBER/OCTOBER 2016 | Volume 39 • Number 5
ty-related overuse may play a role, and individuals participating in activities involving large loads on the gluteus maximus
should be cognizant of maintaining proper
conditioning. Although calcific tendinitis of the gluteus maximus may be selflimiting, patients with recalcitrant disease
may respond well to surgical excision.
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